Transcript Department of Human Services Division of Medical Services

Department of Human Services
Division of Medical Services
Eugene Gessow
Director
ARKANSAS MEDICAID ENTERPRISE
PAGE 1
• The Arkansas Medicaid Enterprise (AME) will be: all of the people,
processes, hardware, software, policies and procedures that are necessary
to run a nimble, effective, efficient, disciplined Medicaid program in a time
of change and with limited resources.
• Arkansas must change the way it manages the Medicaid program, and
Medicaid, as the state’s largest payer, must be a leader in “bending the
curve” in reducing health care costs.
• The business processes will be designed to accommodate the information
needs and business methods of today and tomorrow, will be fully
electronic, and will be able to obtain, process, and exchange information
in real time.
ARKANSAS MEDICAID ENTERPRISE
PAGE 2
• The Medicaid Management Information System (MMIS) will be replaced
with an array of commercial-off-the-shelf (COTS) products that are
selected as the “best of breed” to meet the information management
requirements for both the transactional processing, to make payments
and support eligibility, and the analytical needs for program management,
outcomes analysis, predictive modeling, and detecting fraud and abuse.
• The MMIS Replacement will be designed to interoperate and exchange
both administrative and clinical data through the Arkansas Health
Information Exchange (HIE). Where practical, HIE and MMIS will adopt a
common infrastructure and technical governance.
ARKANSAS MEDICAID ENTERPRISE
PAGE 3
• Providers will have greater access to current and historical information
about members to improve quality, efficiency, and effectiveness of care,
coordinate care, and perform targeted case management.
• Providers will be expected to use information to effectively manage care
and will be able to obtain information as necessary to facilitate care
management.
• Members will have greater access to information, which will help them
find providers, improve individual health practices, and become engaged
in their health care.
ARKANSAS MEDICAID ENTERPRISE
PAGE 4
• The AME will enable DMS to establish enterprise-wide goals and
objectives with the means to measure Medicaid program performance
metrics and contractor performance requirements.
• The AME will strengthen direct lines of authority and accountability by
Medicaid staff for the operation and direction of the Medicaid Program.
CMS PROPOSED RULE FOR ENHANCED FFP
CMS-2346-P
PAGE 5
CMS has recently issued a proposed rule for Medicaid
enterprises
“We are proposing to define MITA at §433.111(c) in this rule
and we propose to build on the work of MITA by codifying
that enhanced FFP (either at the 90 percent rate for design,
development, installation or enhancement; or at the 75
percent rate for maintenance and operations) is only
available when certain standards and conditions are met.
Specifically, we articulate a set of standards and conditions
that States must commit to in order to receive enhanced FFP:”
CMS PROPOSED RULE FOR MEDICAID ENTERPRISE
PAGE 6
1.
Use of a modular, flexible approach to systems development, including
the use of open interfaces and exposed application programming
interfaces; the separation of business rules from core programming; and
the availability of business rules in both human and machine readable
formats.
2.
Align to and advance increasingly in Medicaid Information Technology
Architecture (MITA) maturity for business, architecture, and data.
3.
Ensure alignment with, and incorporation of, industry standards
4.
Promote sharing, leverage, and reuse of Medicaid technologies and
systems within and among States.
CMS PROPOSED RULE FOR MEDICAID ENTERPRISE
PAGE 7
5.
Support accurate and timely processing of claims (including claims of
eligibility), adjudications, and effective communications with providers,
beneficiaries, and the public.
6. Produce transaction data, reports, and performance information that
would contribute to program evaluation, continuous improvement in
business operations, and transparency and accountability.
7. Ensure seamless coordination and integration with the Exchange (whether
run by the State or Federal government), and allow interoperability with
health information exchanges, public health agencies, human services
programs, and community organizations providing outreach and
enrollment assistance services.
Functional Overview of System and Business Services
Business
Offices
Provider
Management
Member
Management
Claims
Receipt,
Adjudication,
Payment &
Adjustments
Care
Management;
Program
Integrity
Audits
Financial
Management
Rates and
Costs
Revenue
Collection
& TPL Operations
Medical
Management
Authorize
Service
System
Support
System Integrator
Contract Management Dashboard
Enterprise Service Bus / Technical Services / Workflow Management / Document Management/ Rules Engine
Enterprise Data Model
State Data Center
System
Modules
Member
Provider
Local LAN
PC / Desktop Support
MMIS Operations
Telephone System
Health Information
Exchange (HIE)
Provider
Services
Web Portal
DSS / Data
Warehouse
TPL /
COB
Program Integrity
Fraud & Abuse
Detection
Pharmacy POS
and PBM
Shared
Services
Core Claims;
Other Payments
Authorize
Services and
Treatment
Plan
Case/Diag.
Mgm’t
Registry
Accounting
Services
Master
Client
Index
HOUSE AND SENATE INTERIM COMMITTEES ON PUBLIC HEALTH
Report on the Medicaid Management Information System (MMIS)
PAGE 9
Questions